=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679020226
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERNAL REVOLUTION COUNSELING AND CONSULTING, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2016
-----------------------------------------------------
Last Update Date | 03/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1123 GRAND AVENUE SUITE 201
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-356-1566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3125 37TH AVE SOUTH
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55406-2134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-787-7583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. ANESH PATEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-356-1566
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | LP5711
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------